Solanky Dipesh, Pardi Darrell S, Loftus Edward V, Khanna Sahil
Mayo Clinic School of Medicine, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA.
Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.
Inflamm Bowel Dis. 2019 Feb 21;25(3):610-619. doi: 10.1093/ibd/izy291.
Inflammatory bowel disease (IBD) is an independent risk factor for Clostridium difficile infection (CDI), and CDI often precipitates IBD exacerbation. Because CDI cannot be distinguished clinically from an IBD exacerbation, management is difficult. We aimed to assess factors associated with adverse outcomes in IBD with CDI, including the role of escalating or de-escalating IBD therapy and CDI treatment.
Records for patients with IBD and CDI from 2008 to 2013 were abstracted for variables including IBD severity before CDI diagnosis, CDI management, subsequent IBD exacerbation, CDI recurrence, and colon surgery. Colon surgery was defined as resection of any colonic segment within 1 year after CDI diagnosis.
We included 137 IBD patients (median age, 46 years; 55% women): 70 with ulcerative colitis (51%), 63 with Crohn's disease (46%), and 4 with indeterminate colitis (3%). Overall, 70% of CDIs were mild-moderate, 14% were severe, and 15% were severe-complicated. Clostridium difficile infection treatment choice did not vary by infection severity (P = 0.27). Corticosteroid escalation (odds ratio [OR], 5.94; 95% confidence interval [CI], 2.03-17.44) was a positive predictor of colon surgery within 1 year after CDI; older age (OR, 0.09; 95% CI, 0.01-0.44) was a negative predictor. Modifying the corticosteroid regimen did not affect CDI recurrence or risk of future IBD exacerbation. Adverse outcomes did not differ with CDI antibiotic regimens or biologic or immunomodulator regimen modification.
Corticosteroid escalation for IBD during CDI was associated with higher risk of colon surgery. Type of CDI treatment did not influence IBD outcomes. Prospective studies are needed to further elucidate optimal management in this high-risk population.
炎症性肠病（IBD）是艰难梭菌感染（CDI）的独立危险因素，且CDI常促使IBD病情加重。由于临床上无法将CDI与IBD病情加重区分开来，因此治疗颇具难度。我们旨在评估IBD合并CDI时与不良结局相关的因素，包括加强或减弱IBD治疗及CDI治疗的作用。
提取2008年至2013年IBD合并CDI患者的记录，记录变量包括CDI诊断前的IBD严重程度、CDI治疗、随后的IBD病情加重、CDI复发以及结肠手术情况。结肠手术定义为在CDI诊断后1年内切除任何结肠段。
我们纳入了137例IBD患者（中位年龄46岁；55%为女性）：70例为溃疡性结肠炎（51%），63例为克罗恩病（46%），4例为未定型结肠炎（3%）。总体而言，70%的CDI为轻-中度，14%为重度，15%为重度合并并发症。艰难梭菌感染的治疗选择不因感染严重程度而异（P = 0.27）。CDI后1年内结肠手术的阳性预测因素为皮质类固醇激素剂量增加（比值比[OR]，5.94；95%置信区间[CI]，2.03 - 17.44）；年龄较大（OR，0.09；95% CI，0.01 - 0.44）为阴性预测因素。调整皮质类固醇激素治疗方案不影响CDI复发或未来IBD病情加重的风险。不良结局在CDI抗生素治疗方案或生物制剂或免疫调节剂治疗方案调整方面并无差异。
CDI期间IBD的皮质类固醇激素剂量增加与结肠手术风险较高相关。CDI治疗类型不影响IBD结局。需要进行前瞻性研究以进一步阐明这一高危人群的最佳治疗方法。
